Continuous peritoneal dialysis (CPD) in children has been an important mode of renal replacement therapy (RRT) since 1978. Continuous ambulatory peritoneal dialysis (CAPD) was used initially in children and then, in infants. Automated peritoneal dialysis (APD) was introduced in the eighties. Currently. CPD is the predominant mode of RRT in children, and 3/4 of these patients are managed with APD. Certain events have evolved with time, such as: a) growth and nutrition; b) renal osteodystrophy; c) anemia; and d) training. Complications from CPD continue to be a challenge and include: a) peritonitis; b) hernias and c) stress. Future directions in pediatric CAPD are: a) applying techniques to measure dialysis adequacy; b) improvement in dialysis solutions, such as pH, osmolality and different osmotic agents; c) additives to the dialysis fluid, such as hormones, growth factors; d) improvements in catheters and cyclers; and e) strategies to reduce peritonitis rates. There are challenges for CPD in the future; however, it appears to be the most practical and cost-effective dialysis therapy for children with end-stage renal disease.

A total of 712 patients with renal problems, aged 13 years or below (mean age 4.12 years) were seen in the Department of Health and Medical Services Hospitals in Dubai in the period from 1991 to 1996. The male to female ratio was 1:1.1. UAE citizens constituted 32% of the total, with a male to female ratio of 1:1.2. Nephrotic syndrome (26.3%) had the highest prevalence among the renal diseases seen, followed by urinary tract infection (19.1%), glomerulonephritis (GN) (9.7%), congenital renal anomalies (9.7%), and chronic renal failure (CRF) (7%). Congenital renal anomalies were the main cause of CRF in our patients followed by GN. Acute renal failure (ARF) occurred in 1.4% of the patients and was not an alarming problem; it had an uncomplicated course and good prognosis. Continuous ambulatory peritoneal dialysis was the mode of replacement therapy for patients with end-stage renal disease. Eight patients underwent renal transplantation; one cadaver donor, four living non-related donor (abroad) and three living related donor.

This study was performed to evaluate the short and long-term outcome of pediatric renal transplantation in Saudi Arabia. Four large centers participated in this study and there were 124 patients with evaluable data. They included 79 males and 45 females with ages ranging from 2­18 years with a mean of 12.2 years. There were 69 transplants from living donors and 55 from cadaveric donors. The cause of the original renal disease was unknown in 61.4% of the cases. Re-transplantation rate was 8% and the cause of failure of the first graft was venous thrombosis in 60% of the cases most of whom were transplanted before 1990. Acute rejection occurred in 31% of the patients and did not correlate with age at time of transplantation, sex, nationality, source of donor, place of transplantation or follow-up, year of transplant, or delayed graft function; however, those who eventually lost their grafts had significantly more number of acute rejection episodes. There were 24 cases (19%) of infection related to graft and 43 cases (34%) of extra-renal infection. Medical complications other than rejection and infection occurred in 37% of the study group. The 15 year survival rates of patients and grafts from living donors were 96.7% and 92.2% respectively, while the 11 year survival rates of patients and grafts from cadaver donors were 93% and 58.4% respectively. We conclude that pediatric renal transplantation in Saudi Arabia has been performing well in terms of the quantity and quality and the results are comparable to the reputed programs in other countries.

Spectrum of Glomerular Disease Among Children in Saudi ArabiaEssam Al-SabbanJuly-September 1997, 8(3):285-288PMID:18417807

A total of 376 renal biopsies performed in several hospitals in Riyadh, on children with glomerulonephritis were reviewed. Focal segmental glomerulosclerosis (FSGS) was the most common glomerulopathy found and accounted for 120 cases (31.9%), followed by mesangial proliferative glomerulonephritis in 99 (26.3%). Minimal change nephrotic syndrome was seen in 55 (14.6%), membranoproliferative glomerulonephritis in 30 (8.0%), membranous glomerulonephritis in 18 (4.8%), IgA nephropathy in 15 (4.0%), post-infectious glomerulonephritis in 15 (4.0%), Alport syndrome in 14 (3.7%) and rapidly progressive glomerulonephritis in 10 (2.7%). Our findings show a high prevalence of FSGS in comparison with most international renal pathological studies published in children. At the same time, there is a relatively low prevalence of IgA nephropathy as compared to some other Asian countries. Additional, more comprehensive, clinical and pathological studies on Saudi children with glomerular diseases are needed to confirm or negate these findings. Environmental and genetic factors have to be explored and studied for their role related to these differences. Also, there is an urgent need to establish a glomerulonephritis registry for children in Saudi Arabia.

Percutaneous Renal Biopsy and its Findings in Children and Adolescents in Saudi Arabia: A Single Center ExperienceLubna Al Menawy, John Amuosi, KS Ramprasad, Faissal A.M ShaheenJuly-September 1997, 8(3):289-293PMID:18417808

A retrospective study of 108 consecutive renal biopsies in children and adolescents below 18 years of age performed at the King Fahd Hospital, Jeddah, during an eight-year period ending 1996, was made. All the biopsies were performed by a single consultant nephrologist and under ultrasound guidance. Tru-cut needles were employed in all cases and in the last two years, the bioptic gum was used. The age of the patients ranged between 3 months and 18 years with a mean of 10.6 years. There were 58 males and 50 females. All patients tolerated the biopsy well and there were no failures. The common side effects noted included gross hematuria in three (2.8%) and severe pain at the biopsy site in 11 (10.2%). None of the patients needed blood transfusions or prolonged hospitalization. Nephrotic syndrome was the commonest indication for performing the biopsy (83.3%) and among them, minimal change was the commonest lesion found (25%) followed by focal and segmental glomerulosclerosis (14.8%) and mesangial proliferative glomerulonephritis (15.7%). Our study further shows that renal biopsy is a safe procedure in children and the commonest indication is nephrotic syndrome.

Sixty two children aged 12 years or below, with chronic renal failure (CRF) were admitted to Asir Central Hospital, Saudi Arabia, in the period from June 1990 to June 1995. Of them, 39 (63%) were in CRF while 23 (37%) were in end-stage renal failure (ESRF) at the time of presentation giving a mean annual incidence for CRF of 15.6 and for ESRF of 9.2 per million children. The male to female ratio was 1.8:1. The mean age of the children was 5.5 years (age range 20 days to 12 years). Urinary system anomalies (including urinary tract anomalies) were the leading cause of CRF (64.5%) followed by gloraerulopathies (17.7%). In those who presented before the age of six years, SO.9% had CRF caused by urinary system anomalies (including inherited kidney anomalies such as polycystic disease) while such anomalies accounted for only 30% of CRF in children older than six years. Glomerulopathies were the leading cause (45%) of CRF in this latter group. We conclude that our mean annual incidence of CRF and ESRF is high and urinary system anomalies constitute the commonest cause among children in our region. Early diagnosis should therefore be encouraged to ensure early treatment of these anomalies, thus decreasing the incidence of CRF.

In this paper we describe our experience with chronic ambulatory peritoneal dialysis (CAPD) in children. Between 1984 and 1993, a total of 51 patients were treated by CAPD at King Khalid University Hospital. Eight patients were excluded from the study because of incomplete data. There were 25 boys and 18 girls aged three months to 16 years; 12 patients (27.9%) were below two years, 15 patients (34.9%) were between 2-6 years, and 16 patients (37.2%) were above six years of age. Reflux nephropathy secondary to obstructive uropathy was the main cause of ESRD in the study patients (27.9%). The total period of CAPD was 579 patient-months (48.25 years). The overall incidence of peritonitis was high, one episode per 4.7 patient months; one episode per 3.2 patient months in the first five years of the study and one episode per 6.2 patient-months in the 2nd five years of the study period. The cause of peritonitis was gram positive organisms in 38.7% and gram negative organisms in 24.9%. Seventeen (39.5%) of catheters were changed because of infection or mechanical obstruction. In 90.7% of patients, the mother was the person who was performing dialysis. At the end of the study, seven patients (16.2%) were still on CAPD, 10 patients (23.3%) shifted to heraodialysls, 16 patients (37.2%) were transplanted, six patients (14.0%) died and four patients (9.3%) recovered. We conclude that CAPD may be a suitable renal replacement therapy for children in a country with a wide geographical area and low population density as Saudi Arabia.